End of life/palliative care/ethics. Emerg Med Clin North Am. 2014;32:955-974. [PMID: 25441045 DOI: 10.1016/j.emc.2014.07.010]

Perception of Medical Students on the Need for End-of-Life Care: A Q-Methodology Study

End-of-life care and the limitation of therapeutic effort are among the most controversial aspects of medical practice. Many subjective factors can influence decision-making regarding these issues. The Q methodology provides a scientific basis for the systematic study of subjectivity by identifying different thought patterns. This methodology was performed to find student profiles in 143 students at Cantabria University (Spain), who will soon deal with difficult situations related to this topic. A chi-square test was used to compare proportions. We obtained three profiles: the first seeks to ensure quality of life and attaches great importance to the patient’s wishes; the second prioritizes life extension above anything else; the third incorporates the economic perspective into medical decision-making. Those who had religious beliefs were mostly included in profile 2 (48.8% vs. 7.3% in profile 1 and 43.9% in profile 3), and those who considered that their beliefs did not influence their ethical principles, were mainly included in profile 3 (48.5% vs. 24.7% in profile 1 and 26.8% in profile 2). The different profiles on end-of-life care amongst medical students are influenced by personal factors. Increasing the clinical experience of students with terminally ill patients would contribute to the development of knowledge-based opinion profiles and would avoid reliance on personal experiences.

Physician-Patient Relationship, Assisted Suicide and the Italian Constitutional Court

In 2017, Italy passed a law that provides for a systematic discipline on informed consent, advance directives, and advance care planning. It ranges from decisions contextual to clinical necessity through the tool of consent/refusal to decisions anticipating future events through the tools of shared care planning and advance directives. Nothing is said in the law regarding the issue of physician assisted suicide. Following the DJ Fabo case, the Italian Constitutional Court declared the constitutional illegitimacy of article 580 of the criminal code in the part in which it does not exclude the punishment of those who facilitate the suicide when the decision has been freely and autonomously made by a person kept alive by life-support treatments and suffering from an irreversible pathology, the source of physical or psychological suffering that he/she considers intolerable, but fully capable of making free and conscious decisions. Such conditions and methods of execution must be verified by a public structure of the national health service, after consulting the territorially competent ethics committee. This statement admits, within strict and regulated bounds, physician assisted suicide, so widening the range of end-of-life decisions for Italian patients. Future application and critical topics will be called into question by the Italian legislator.

The relationship between nurses' knowledge and self-confidence in implementing palliative care in an intensive care unit

BACKGROUND

This quantitative study aimed to analyse the relationship between knowledge and nurses' self-confidence (or self-efficacy) in applying palliative care (PC) in the intensive care unit (ICU). This study was a correlational study with a cross-sectional approach. The sampling technique used was total sampling, and the sample included all nurses who were actively working at the general hospital in Bandung, West Java, Indonesia, during the study. There were 127 people in total. Data were collected using questionnaires. The Pearson correlation test was used for bivariate analysis. The results of univariate analysis showed that the majority of respondents had high self-confidence but had less knowledge related to PC in the ICU. Based on the results of the bivariate analysis, there was a significant relationship between knowledge and self-confidence variables. The results showed that a high number of respondents had less knowledge in implementing PC in the ICU. Therefore, familiarisation sessions and training related to this are needed, focusing on nurses' beliefs in their abilities.

Resuscitating the Critically Ill Geriatric Emergency Department Patient

The emergency department resuscitation of the critically ill geriatric patient is challenging and can be fraught with peril. The anatomic and physiologic changes that occur with aging can significantly influence the recognition of critical illness and the logistics of resuscitation itself. This article discusses the relevant physiologic changes with aging, the effect of these changes on clinical manifestations of critical illness in older adults, and the core principles of resuscitation in this population, with specific attention to sepsis and trauma care. In addition, end-of-life care is also discussed.

Factors Associated with Nurses’ Self-Efficacy in Applying Palliative Care in Intensive Care Unit

Introduction: The increasing need for palliative care (PC) in the intensive care unit (ICU) is characterised by an increasing number of patients with critical and terminals conditions. It requires comprehensive treatment of nurses, through PC. Self-efficacy is a major predictor that affects the application of PC in ICU. Therefore, nurses need to have high self-efficacy to provide quality PC for patients and their families. This study aimed to analyse the factors that dominant relates to nurses' self-efficacy in implementing of providing PC in ICU.Methods: This research was correlational research with cross-sectional survey design. The sampling technique used was total sampling, which involved 127 critical nurses who were actively working at a general hospital in Bandung, Indonesia. Data were collected using questionnaires. Bivariate analysis using Pearson correlation and Rank-Spearman test and multivariate analysis using linear regression.Results: The results showed that the majority of respondents had high self-efficacy, working experience >15 years, enough interest to the nursing profession had less knowledge and negative perception related to the PC in ICU. There was a significant relationship between self-efficacy with work experience, nurses' interest in the nursing profession, knowledge and perception variables. The most dominant factors related to self-efficacy, namely knowledge and perceptions of nurses related to PC.Conclusion: This study indicates that majority of the respondents lacked knowledge and had negative perceptions related to PC in ICU, it is necessary to socialise and training related to it by focusing on self-belief or self-efficacy of nurses on their ability.

Should Emergency Department Patients with End-of-Life Directives be Admitted to the ICU?

BACKGROUND

Whether emergency physicians should utilize critical care resources for patients with advance care planning directives is a complex question. Because the cost of intensive care unit (ICU)-level care, in terms of human suffering and financial burden, can be considerable, ICU-level care ought to be provided only to those patients who would consent and who would benefit from it.

OBJECTIVES

In this article, we discuss the interplay between clinical indications, patient preferences, and advance care directives, and make recommendations about what the emergency physician must consider when deciding whether a patient with an advance care planning document should be admitted to the ICU.

DISCUSSION

Although some patients may wish to avoid certain aggressive or invasive measures available in an ICU, there may be a tendency, reinforced by recent Society of Critical Care Medicine guidelines, to presume that such patients will not benefit as much as other patients from the specialized care of the ICU. The ICU still may be the most appropriate setting for hospitalization to access care outside of the limitations set forward in those end-of-life care directives. On the other hand, ICU beds are a scarce and expensive resource that may offer aggressive treatments that can inflict suffering onto patients unlikely to benefit from them. Goals-of-care discussions are critical to align patient end-of-life care preferences with hospital resources, and therefore, the appropriateness of ICU disposition.

CONCLUSIONS

End-of-life care directives should not automatically exclude patients from the ICU. Rather, ICU admission should be based upon the alignment of uniquely beneficial treatment offered by the ICU and patients' values and stated goals of care.

Palliative Care in the Emergency Department

As the geriatric population increases in the United States, there is an increase in number of visits to emergency departments for end-of-life and palliative care. This provides the emergency physician with a unique opportunity to alleviate and prevent further suffering in this vulnerable population. Competency in communication strategies that support shared decision making and familiarity with medicolegal terminology increase physician confidence about addressing complaints at the end of life. Familiarity with evidence-based recommendations for symptom management of pain at the end of life aids the emergency physician in creating a positive experience for the patient and their loved ones.

End-of-Life Care and Psychiatry: Current Trends and Future Directions in India

Although 80% of the deaths worldwide occur in middle- and low-income countries such as India, there is less awareness of end-of-life care (EOLC) for people with chronic, serious, progressive, or advanced life-limiting illnesses, including dementia. EOLC involves good communication, clinical decision-making, liaison with medical teams and families, comprehensive assessment of and specialized interventions for physical, psychological, spiritual, and social needs of patients and their caregivers. The psychiatrist can play a significant role in each of the above domains in EOLC. The current trends in India are examined, including ambiguities between EOLC and euthanasia. Future directions include formulating a national EOLC policy, providing appropriate services and training. The psychiatrist should get involved in this process, with major responsibilities in providing good quality EOLC for patients with both life-limiting physical illnesses and severe mental disorders, supporting their caregivers, and ensuring dignity in death.

Integrating palliative care in oncologic emergency departments: Challenges and opportunities

Although visiting the emergency departments (EDs) is considered poor quality of cancer care, there are indications these visits are increasing. Similarly, there is growing interest in providing palliative care (PC) to cancer patients in EDs. However, this integration is not without major challenges. In this article, we review the literature on why cancer patients visit EDs, the rates of hospitalization and mortality for these patients, and the models for integrating PC in EDs. We discuss opportunities such integration will bring to the quality of cancer care, and resource utilization of resources. We also discuss barriers faced by this integration. We found that the most common reasons for ED visits by cancer patients are pain, fever, shortness of breath, and gastrointestinal symptoms. The majority of the patients are admitted to hospitals, about 13% of the admitted patients die during hospitalization, and some patients die in ED. Patients who receive PC at an ED have shorter hospitalization and lower resource utilization. Models based solely on increasing PC provision in EDs by PC specialists have had modest success, while very limited ED-based PC provision has had slightly higher impact. However, details of these programs are lacking, and coordination between ED based PC and hospital-wide PC is not clear. In some studies, the objectives were to improve care in the communities and reduce ED visits and hospitalizations. We conclude that as more patients receive cancer therapy late in their disease trajectory, more cancer patients will visit EDs. Integration of PC with emergency medicine will require active participation of ED physicians in providing PC to cancer patients. PC specialist should play an active role in educating ED physicians about PC, and provide timely consultations. The impact of integrating PC in EDs on quality and cost of cancer care should be studied.

The Integration of Palliative Care into the Emergency Department

Palliative care (PC) is a new and developing area. It aims to provide the best possible quality of life for patients with life-limiting diseases. It does not primarily include life-extending therapies, but rather tries to help patients spend the rest of their lives in the best way. PC patients often are admitted to emergency departments during the course of a disease. The approach and management of PC include differences with emergency medicine. Thus, there are some problems while providing PC in the ED. With this article, the definition, main features, benefits, and problems of providing PC are presented, with the primary aim of emphasizing the importance of PC integration into the ED.

Managing paediatric death in the emergency department

Death of a child in an emergency department is a rare occurrence, but one with significant impact on the family and staff involved. The rarity means few emergency department clinicians feel 'expert' in the overall management process. However, most have some knowledge and experience which can be augmented by collaborating with other health professionals. By exploring some of the main management issues and challenges for the emergency department, key aspects of care are identified for emergency department clinicians to consider in reviewing local procedures and guidelines.